Provider Demographics
NPI:1336806801
Name:MEMORIAL MEDICAL GROUP OF SOUTH FLORIDA, LLC
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL GROUP OF SOUTH FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMSC, PAC
Authorized Official - Phone:754-273-0885
Mailing Address - Street 1:16000 PINES BOULEVARD
Mailing Address - Street 2:#822503
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33082-2503
Mailing Address - Country:US
Mailing Address - Phone:754-273-0885
Mailing Address - Fax:754-240-7841
Practice Address - Street 1:4000 HOLLYWOOD BLVD STE 555S
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6853
Practice Address - Country:US
Practice Address - Phone:754-273-0885
Practice Address - Fax:833-955-3596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty